Provider Demographics
NPI:1588707343
Name:OSBORNE, MILDRED BYNOE (MD)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:BYNOE
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MILLIE
Other - Middle Name:BYNOE
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3302 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3353
Mailing Address - Country:US
Mailing Address - Phone:703-207-7100
Mailing Address - Fax:
Practice Address - Street 1:3302 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3353
Practice Address - Country:US
Practice Address - Phone:703-207-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010443942084P0800X, 2084P0805X
DCMD0379262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0049-4504-2Medicaid